HealthFirst for Clinton County (Ohio)
Donor Information (please print or type)
Name _____________________________________
Address __________________________________
City _______________________________________
State ______________________________________
Zip Code _________________________________
Phone ____________________________________
Email _____________________________________
Pledge Information
I (we) pledge a total of $____________________ to be paid: ☐now ☐monthly ☐quarterly ☐yearly.
I (we) plan to make this contribution in the form of: ☐cash ☐check
Gift will be matched by (company/family/foundation)
☐form enclosed☐form will be forwarded
Acknowledgement Information
Please use the following name(s) in all acknowledgements: ________________________________________________________________
☐ I (we) wish to have our gift remain anonymous.
Signature(s) __________________________________________________ Date ___________
Please make checks, corporate matches,
or other gifts payable to:
HealthFirst for Clinton County
Clinton County Foundation
POB 831
Wilmington, Ohio 45177
Donor Information (please print or type)
Name _____________________________________
Address __________________________________
City _______________________________________
State ______________________________________
Zip Code _________________________________
Phone ____________________________________
Email _____________________________________
Pledge Information
I (we) pledge a total of $____________________ to be paid: ☐now ☐monthly ☐quarterly ☐yearly.
I (we) plan to make this contribution in the form of: ☐cash ☐check
Gift will be matched by (company/family/foundation)
☐form enclosed☐form will be forwarded
Acknowledgement Information
Please use the following name(s) in all acknowledgements: ________________________________________________________________
☐ I (we) wish to have our gift remain anonymous.
Signature(s) __________________________________________________ Date ___________
Please make checks, corporate matches,
or other gifts payable to:
HealthFirst for Clinton County
Clinton County Foundation
POB 831
Wilmington, Ohio 45177